MEDICARE: JESSICA FUKUSHIMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	110471	CA

General Provider Information

NPI Number	:	1699468876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA FUKUSHIMA

Provider Business Mailing Address
First Line	:	6451 CAPPS AVE
Second Line	:
City	:	RESEDA
State	:	CA
Zip	:	91335-6007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10445 LAUREL CANYON BLVD
Second Line	:
City	:	PACOIMA
State	:	CA
Zip	:	91331-3605
Country	:	US
Telephone Number	:	818-890-8070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2023
Last Update Date	:	09/06/2024

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